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Harry K. Tweel, MD Physician Director
Cabell-Huntington Health Department
Public Health Role in
Tuberculosis control August 2, 2013
True/ False Questions 1. Tuberculosis outbreaks occur about in
WV about every 4 to 5 years.
2. Tuberculosis is highly contagious.
3. Prophylactic tuberculosis therapy is over 90% effective in preventing future progressive (active) tuberculosis in an individual whom has been recently infected.
True/ False Questions 4. Young children exposed to a parent
with active tuberculosis often have a negative PPD skin test because they are more resistant to becoming infected.
5. In West Virginia close contacts of known active cases can not be forced to be evaluated even if they have a positive PPD.
HISTORY OF TUBERCULOSIS TB: Major Cause of Suffering and Death
First human case 3400 BC Consumption, White Plague, scrofula, King’s Evil, pthisis England 1815: 1 in 4 deaths France 1918: 1 in 6 deaths During 20thC, TB killed ~100
million
Timothy Cratchit aka Tiny Tim
Tiny Tim known based on invalid son of Dicken’s friend 1997 Excavation at St. Andrew’s Church found 19C gravesite ‘‘In Memory. Timothy Cratchit. 1839–1884,
Beloved Husband of Julia, Father of Robert, and Son of Robert and Martha.’’
Skeletal remains of 40yo man wearing metal frame and leather on legs and back
PCR confirmed Tuberculosis*
*CW Callahan. JID 1997;176:1653–4
HISTORY OF TUBERCULOSIS
At the height of the Romantic movement tuberculosis was declared to be:
“The mark of spirituality or the wages paid by those seemingly touched by a burning creativity.”
HISTORY OF TUBERCULOSIS
Mark of beauty-pale consumptive look
1858 painting of Queen Guinevere by William Morris
La Boheme- Mimi
La Dame aux Camelias- Margrerite
“I look pale . . . I should like to die of
consumption – because the ladies
would say „Look at poor Byron, how
interesting he looks in dying‟.” Lord Byron (1788-1824)
HISTORY OF TUBERCULOSIS
Robert Koch(1843-
1910)
Discovery
Tuberculosis
bacillus
April 10, 1882
Berlin Physiological
Society
HISTORY OF TUBERCULOSIS
Sanatorium Movement
National association for the study and prevention of tuberculosis 1904.
Rapid growth.
11,953 beds in 1908
30,000 beds in 1915
97,726 beds in 1942 (peak)
HISTORY OF TUBERCULOSIS Tuberculosis Nursing
Tuberculosis today Still a Major Cause of Suffering and Death
One third of the world’s population are
infected with TB
9 million people worldwide become sick with TB each year
2 million will die each year of TB related disease
TB is the leading killer of people who are HIV infected.
Tuberculosis in WV Year Active cases New cases Deaths
1950 6,107 2,099 428
1960 4,563 676 105
1970 3,077 329 65
1980 ---- 203 10.4
1990 ---- 87 4.9
2010 ---- 15 1
2012 ---- 8 0
Tuberculosis 2013 contacts to MDR case Cabell-Huntington Health Department
Public Health Role in Tuberculosis control
Tuberculosis control All aspects of control
Detection
Prevention
Treatment programs
Tuberculosis control Surveillance
Case containment
prevention
Tuberculosis control Source or suspected Case
Confirmed case
Suspected case
Contact investigation concentric circle
Index
case
close
Other-than close
Contact investigation concentric circle / 3 months prior to Rx
Index
case
close
Other-than close
Close contact
8 hr / week
Contact investigation concentric circle
Index
case
close
Other-than close
Household
Leisure
School
homeless
Workplace
Contact investigation
Close contacts most likely to be infected:
1. Contacts to patients with high degree of infectiousness based on the following factors:
Laryngeal or pulmonary Tuberculosis
AFB smear positive
Cavitary disease on Chest X-ray
Cough
Contact investigation
Close contacts most likely to be infected:
2. Contacts exposed to patients in:
Congregate settings
Small or crowded rooms
Areas that are poorly ventilated
Areas without air-cleaning systems
Contact investigation
Close contacts most likely to be infected:
Congregate settings
prison
shelters
nursing homes
single-room-occupancy hotels
health care facilities
Contact investigation
Close contacts most likely to be infected:
Close contacts most likely to be infected:
Contacts who:
Have prolonged exposure (longer
than 8 hours per week during infectious period)
Have been physically close to the patient
Contact investigation Contacts at high risk of developing tuberculosis once infected
1. Contacts who are young children less than 5 years of age.
2. Contacts with any of these conditions:
HIV infection/AIDS or those at high risk for HIV infection who refuse HIV testing.
Injection of drugs
Diabetes mellitus
Silicosis
Contact investigation Contacts at high risk of developing tuberculosis once infected
2. Contacts with any of these conditions:
Prolonged corticosteroid therapy
Immunosuppressive therapy
Chemotherapy
Certain types of Cancers (i. g. Carcinoma of the head, neck , or lungs) or hematological disorders (i. e. leukemia and lymphoma)
Contact investigation Contacts at high risk of developing tuberculosis once infected
2. Contacts with any of these conditions:
Chronic renal failure
Gastrectomy or jejunoileal bypass
Low body weight (10% or greater below ideal)
Fibrotic lesions on CXR consistent with old Tuberculosis
Calculating the infectious period Usually starts 12 weeks prior to treatment and ends
when contact with infected person is removed from interaction with contacts
This period is extended in the case of MDRTB
The period may be extended if history reveals an earlier start of symptoms.
If patient reverts from Negative cultures to Positive a new infectious period must be established. History is critical in this revision.
Disease investigation & Management
Assessing Risk of Transmission based on the characteristics of the source
case AFB smear Positive (higher the smear grade,
higher risk)
Site (pulmonary or laryngeal tuberculosis)
Cavitary disease
Cough or hoarseness
Disease investigation & Management
Assessing Risk of Transmission
Based on environmental factors
Small room size
Poor ventilation (lack of windows)
Disease investigation & Management
Assessing Risk of Transmission
Based on the extent of exposure
Prolonged exposure greater than 8 hours of exposure
Frequent exposure
Close physical proximity (i. e. sleeping in the same
room)
Evaluation & Management of Contacts
All close contacts should be evaluated for symptoms
1. Highest priority for further testing are those who
exhibit symptoms of TB.
Test with:
IPPD or IGRA (t-spot)
Chest X-ray
Sputum smears & cultures (with drug susceptibility testing)
Also look for extra pulmonary sites
Evaluation & Management of Contacts
All close contacts should be evaluated for symptoms
2. Contacts with definite symptoms of TB should be treated: (With or without a positive
chest X-ray finding consistent with TB)
Await TB culture results
Evaluation & Management of Contacts
All close contacts should be evaluated for symptoms
3. Patients with vague symptoms
Withhold treatment until evaluation is complete.
Evaluation & Management of Contacts
All close contacts should be evaluated for symptoms
3. Patients with vague symptoms
Withhold treatment until evaluation is complete.
This includes withholding LTBI treatment
Evaluation & Management of Contacts
All close contacts should be evaluated for symptoms
4. Contacts with symptoms are class 5 (High)
Evaluation & Management of Contacts
All close contacts should be evaluated for symptoms
4. Contacts with symptoms are class 5 (High)
Regardless of initial lab findings:
CXR
IPPD or IGRA
Evaluation & Management of Contacts
HIV testing Who should be tested?
Evaluation & Management of Contacts
HIV testing All contacts
Those with HIV risk behavior should be closely monitored & referred when appropriate.
Evaluation & Management of Contacts
Evaluation & Management of Contacts
Contacts with a negative IPPD or IGRA (class I)
Why are they class 1?
Evaluation & Management of Contacts
Contacts with a negative IPPD or IGRA (class I)
Repeat testing in 8 to 12 weeks.
Of the negative test group who should have an X-ray & clinical evaluation during the 8 weeks period?
Evaluation & Management of Contacts
Contacts with a negative IPPD or IGRA who need a chest X-ray & medical evaluation:
Contacts younger than 5 years of age
Contacts between 5 and 15 years of age at physicians request
Contacts who are HIV positive
Contacts who are Immunosuppressed
HIV risk patients who refuse HIV testing
Evaluation & Management of Contacts
Contacts with a positive IPPD or IGRA
Chest X-ray and physical are normal (class 2)
Chest X-ray or Physical evidence suggest TB (class 5)
Evaluation & Management of Contacts
Contacts with a positive IPPD or IGRA
Chest X-ray and physical are normal (class 2) Start LTBI treatment
Chest X-ray or Physical evidence suggest TB (class 5) Evaluate for TB disease before starting treatment
Evaluation & Management of Contacts
Who needs evaluation & Chest X-ray
All contacts with a positive IPPD or IGRA
Any contact with a prior history of a positive IPPD/IGRA
Any contact with a prior history of TB
Evaluation & Management of Contacts
Who needs evaluation & Chest X-ray
Contacts with HIV or other immunosuppressive conditions with or without a positive IPPD/IGRA
Children less than 5 years of age (regardless of IPPD results)
All persons with symptoms (regardless of IPPD/IGRA results)
Sexual partners of HIV infected contact individuals who refuse HIV testing
Evaluation & Management of Contacts
6 week follow-up testing:
1. Negative test with no further contact to source case (Class 1)
May discontinue LTBI treatment
Evaluation & Management of Contacts
8 week follow-up testing:
1. Negative test with no further contact to source case (Class 1)
May discontinue LTBI treatment
2. Negative test with continues close contact with source case
Continue LTBI if other risk factors
Evaluation & Management of Contacts
8 week follow-up testing:
1. Negative test with no further contact to source case (Class 1)
2. Negative test with continues close contact with source case
Reevaluate every 3 months with a chest X-ray & evaluation
Evaluation & Management of Contacts
Those who have a positive culture during the interim period (Class 5)
Is now a new source case requiring full treatment & new investigation
Evaluation & Management of Contacts
Expanding a contact investigation recommended when the index case fits one or more of these criteria:
Homeless living in a congregate setting, shelter or single-room-occupancy hotel
Works in or attends a school or day care facility
Works in a potentially sensitive worksite
Works in a setting where the coworkers are aware of the TB diagnosis
Evaluation & Management of Contacts
Expanding a contact investigation recommended when the index case fits one or more of these criteria:
Works, studies, or lives in a setting with 15 or mo0re individuals
Is a health care worker
Has traveled during the infectious period for 8 or more hours on an airplane train, or bus.
Attends a place of worship regularly during the infectious period
Evaluation & Management of Contacts
Expanding a contact investigation recommended when the index case fits one or more of these criteria:
Attended an after school program or other extracurricular programs during the infectious period
Frequently in a health care setting during the infectious period
Especially if not appropriately isolated during a hospitalization or frequent clinic visits
Evaluation & Management of Contacts
Latent Tuberculosis infection
Short course therapy (12 weeks) DOT
Standard 6 or 9 months therapy
Source case finding
Regular follow-up
Observe for drug toxic effects
Tuberculosis contact
investigation at the
Cabell-Huntington
Health Department
2013
Tuberculosis in WV Year Active cases New cases Deaths
1950 6,107 2,099 428
1960 4,563 676 105
1970 3,077 329 65
1980 ---- 203 10.4
1990 ---- 87 4.9
2010 ---- 15 1
2012 ---- 8 0
2013 ---- 7 0
Tuberculosis 2013
Cabell-Huntington Health Department Number of new cases
Number of contacts identified
Number of contacts test or Evaluated
Number with LTBI
Number started on treatment after sorting by risk
7 4022 3760 65 45
Tuberculosis 2013
Cabell-Huntington Health Department
Number of LTBI Number who were candidates for LTBI treatment
Number started on treatment
Number who have completed treatment
58 53 45 33
Reasons for not completing LTBI Adverse
Medication reaction
Patient chose to stop
Patient lost to follow-up
1 2 3
Tuberculosis 2013
Cabell-Huntington Health Department Case Contacts Positive PPD Positive T-spot On treatment
1
2
3
4
5
6
7
Tuberculosis is
a social disease
with medical
implications.
True/ False Questions 1. Tuberculosis outbreaks occur about in
WV about every 4 to 5 years.
2. Tuberculosis is highly contagious.
3. Prophylactic tuberculosis therapy is over 90% effective in preventing future progressive (active) tuberculosis in an individual whom has been recently infected.
True/ False Questions 4. Young children exposed to a parent
with active tuberculosis often have a negative PPD skin test because they are more resistant to becoming infected.
5. In West Virginia close contacts of known active cases can not be forced to be evaluated even if they have a positive PPD.
Role of Nursing today in Direct observed Therapy
Tuberculosis Nursing
TBC nursing 2012 pictures
TBC nursing 2012
TBC nursing 2012
TBC nursing 2012
TBC nursing 2012
TBC evaluation & Therapy
TBC evaluation & Therapy
TBC nursing 2012
Summary WV has a high standard for the care of
tuberculosis patients.
The Cabell-Huntington Health Department embraces the challenge & the complexity of proper treatment in order to eliminate tuberculosis. (DOT & contact investigation)
We treat these patients with respect and compassion for our best chance of success
Eliminate tuberculosis in the US Good contact investigation with proper
follow-up & therapy. (HIPAA)
Close monitoring of therapy of active cases with DOT & labs
Testing all active cases for HIV & MDR & XMD.
Testing of high risk individuals
Knowledge of co-morbidities
summary Great need exists for new drugs/regimens to address
the unmet medical needs in TB therapy
Ultimate success will require still stronger and more robust global TB drug pipeline
New approach underway for the development of novel anti-TB drug regimens (CPTR initiative)
Questions
Thank you
Harry K. Tweel, MD Physician Director
Cabell-Huntington Health Department
Public Health Role in
Tuberculosis control August 2, 2013
